Sprained Ankle

What is a sprain?

A sprain is an injury to a ligament. Ligaments are strong tissues around joints which attach bones together. They give support to joints. A ligament can be injured, usually by being stretched during a sudden pull. The ligaments around the ankle are the ones most commonly sprained.

The severity of a sprain is graded into:

• Grade I - mild stretching of the ligament without joint instability.
• Grade II - partial rupture (tear) of the ligament but without causing joint instability.
• Grade III - complete rupture (tear) of the ligament with instability of the joint.

A damaged ligament causes inflammation, swelling, and bleeding (bruising) around the affected joint. Movement of the ankle joint is painful when you have a sprained ankle.

What is the aim of treatment?

Usually, the damaged ligament heals by itself over time. Some scar tissue may be produced where there has been a tearing of tissues. The main aims of treatment are to keep inflammation, swelling, and pain to a minimum, and to be able to use the ankle joint normally again as quickly as possible.

What is the treatment of a sprained ankle?

For the first 48-72 hours think of:

• Paying the PRICE - Protect, Rest, Ice, Compression, Elevation, and
• Do no HARM - No Heat, Alcohol, Running or Massage

• Do not stop moving the joint. Don't do anything that causes much pain, but gently get the joint moving again. Sometimes it means doing gentle exercises several times a day. The aim is to get the ankle joint moving in all normal directions, and to prevent it becoming stiff.
• Consider wearing some sort of ankle support whilst going about your normal activities until symptoms have gone. For example, a semi-rigid support. This aim is to give some support to the joint whilst the damaged ligament is healing, but to allow the ankle to be able to move to a reasonable degree.
• Physiotherapy may help for more severe sprains, or if symptoms are not settling. A physiotherapist can advise on exercises and may give heat, ultrasound, or other treatments. The aim of physiotherapy includes:
  • To get the ankle joint back to a full range of normal movement.
  • To improve the strength of the surrounding muscles. The stronger the muscles, the less likely a sprain will recur.
  • Exercises designed to improve proprioception. This is the ability of your brain to sense movement and position of your body parts and joints such as the ankle. Good proprioception helps you to make immediate, unconscious minor adjustments to the way you walk when walking over uneven ground. This helps to prevent you overstretching ligaments and causing further sprains.
• You should not play sport or do vigorous exercise involving the ankle for at least 3-4 weeks after the injury.

What about medication?

You may not need any medication if the sprain is mild and you can tolerate the pain. If needed, painkiller options include the following:

Paracetamol and codeine

Paracetamol is useful to ease pain. It is best to take paracetamol regularly, for a few days or so, rather than every now and then. An adult dose is two 500 mg tablets, four times a day. If the pain is more severe, a doctor may prescribe codeine which is more powerful, but can make some people drowsy and constipated.

Anti-inflammatory painkillers

These drugs are also called nonsteroidal anti-inflammatory drugs (NSAIDs). They relieve pain and may also limit inflammation and swelling. There are many types and brands. You can buy two types (aspirin and ibuprofen) at pharmacies without a prescription. You need a prescription for the others. Side-effects sometimes occur with anti-inflammatory painkillers. Stomach pain, and bleeding from the stomach, are the most serious. Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take anti-inflammatory painkillers. So, check with your doctor or pharmacist before taking them to make sure they are suitable for you.

But note: Clinical Knowledge Summaries, a well known source of guidance for doctors in the UK (cited below), do not recommend that anti-inflammatory painkillers should be used in the first 48 hours after the injury. This is because of concerns that they may delay healing. The logic is that some inflammation is a necessary part of the healing process. So, it may be that decreasing inflammation too much by taking these drugs may impair the healing process. This may be a theoretical concern as no trials have proven this point. Also, this view is in contrast to what is said in the article from the 'American Family Physician' (cited below). This states that "some studies have shown that patients with ankle sprain showed that, compared with placebo (dummy tablet), NSAIDs were associated with improved pain control and function, decreased swelling, and more rapid return to activity."

Further research is needed to clarify the use of anti-inflammatory painkillers following an injury.

Rub-on (topical) anti-inflammatory painkillers

Again there are various types and brands. You can buy one containing ibuprofen at pharmacies without a prescription. You need a prescription for the others. There is debate as to how effective rub-on anti-inflammatory painkillers are compared to tablets. Some studies suggest that they may be as good as tablets for treating sprains. Some studies suggest they may not be as good. However, the amount of the drug that gets into the bloodstream is much less than with tablets, and there is less risk of side-effects.

See a doctor if:

You are concerned about the injury or the injury is severe. In particular, if:

• You suspect a bone may be broken or a ligament is ruptured.
• You have a lot of tenderness over a bone.
• The pain is severe, or if you cannot walk because of an injury.
• Bruising is severe.
• Symptoms and swelling do not gradually settle. Most sprains improve after a few days, and the pain gradually eases. However, the pain often takes several weeks to go completely, especially when you use the injured joint.

Preventing sprains

You can help to prevent ankle sprains by wearing boots that give ankle support rather than shoes when hiking across country or rambling over hills and uneven ground. Boots are often best for manual labourers too.

Also, exercises to build up the muscles around the ankle and to improve proprioception (described earlier) help to prevent ankle sprains. A physiotherapist can advise on these exercises.